“May mother and newborn live to experience the next full moon”

Integration of Maternal

and Newborn Health Care Meeting September 2014:

Synthesis and Next Steps

Kathleen Hill, URC

Boston, September 9-10th 2014

Meeting Convened by Maternal Health Task Force and Saving Newborn Lives Project

Synthesis, Wrap Up and Next steps

• Meeting Goal and Objectives – Arc of meeting (presentations, small groups, plenary discussion)

• Language/Terminology

• Recurring Themes

• Walking the Talk…Next steps (objective 3)

Meeting Goal and Objectives

Goal: Increase collaboration between maternal and newborn health communities to improve the quality of maternal, fetal and neonatal care

Meeting Objectives: 1. Review knowledge base on the state of the evidence

regarding integration of maternal and newborn health care and the promising approaches, models and tools that exist for moving this agenda forward

2. Identify the barriers to and opportunities for integrating maternal and newborn care across the continuum

3. Develop a list of actions the global maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness

Smart Integration for who and for what purpose?

--------------------------------------------------- • Outcomes that matter to mothers, newborns

and families (health, social, experience of care, access/equity)

• Pursuing quality and equity • Align action all levels (global/national policy and

systems) on smart integrated service delivery processes for mothers and newborns to achieve people-centered care and good outcomes

Meeting Objective 1: Review knowledge base on state of the evidence regarding MNH integration (little evidence) and promising approaches models and tools -------------------------------------------------------------------------------------- -Integration in pursuit of quality and equity -Performance gaps - Documented low coverage of delivery/post-partum MNH interventions

although period of highest mortality for mothers and newborns (delivery/post-partum coverage comparatively lower than for other phases of MNCH continuum – e.g. ANC, childhood immunization coverage)

-Major coverage and quality of care inequities within and across countries -Systems not designed to meet needs of mothers and newborns at same

time in same place (commodities, policy, HMIS, workforce support, organization of care)

-Organizational structures not designed to support integrated MNH programs (MOH structures, academic structures, workforce scope of practice, donor organization, etc.)

“Every system perfectly designed to achieve the results it achieves” -We are stuck in old ways of thinking and outdated organizational structures - We cannot expect different results unless we change the way we organize

our work -Call for paradigm shift/game-changer that looks to problems and solutions

for future…comprehensive people-centered primary care -

Meeting Objective 1 (continued): Review knowledge base on state of evidence regarding MNH integration and promising approaches models and tools ------------------------------------------------------------------------ -Value and limitations of MNCH continuum of care

framework – in fact many continuums w/distinct stakeholders and power interests (routine vs. emergency care, primary vs. specialist provider, urban vs. rural, manager vs. provider)

-Barriers and opportunities (meeting participant survey results)

-Reality, reality, reality…Nafisatou Omar– “work environment is appalling”

Meeting Objective 2: Identify barriers and opportunities for integrating maternal newborn care across continuum (service delivery & system) ------------------------------------------------------------------------- • Barriers/opportunities (national/system)

• Barriers/opportunities (service-delivery)

• Case Studies demonstrating integrated MNH care in low and middle-income settings:

– Cotopaxi/Ecuador

– Sokoto/Nigeria

– Saving Mothers Giving Life

What has not worked? --------------------------------------------------- • “Appropriate (and inappropriate)

compartmentalization in the interest of integration” – Not necessarily always best to chunk by “maternal” and

“newborn” categories – Other categories are also very relevant for integration: e.g.

pregnancy-delivery, post-partum continuum; household to facility continuum

• Context (and non context) driven strategies – Temptation to develop/apply “one-size fits all” strategies – However, problems, contexts and solutions vary by context

and integration strategies must be tailored to context

What can smart integrated care look like? ---------------------------------------------------- • What does woman/newborn/family want and

need at this time (pregnancy, delivery, post-partum)?

• What do health workers/health team and

managers need to support optimal systems and care delivery at this time (ANC, intra-partum and post-partum care)?

• MNH continuum, Normal and complicated

scenarios, systems, service delivery organization

Recurring Themes…. ---------------------------------------------------

• Language matters: our language around integration must be clear, consistent and capture our aspirations. – Do we need a unified definition of maternal newborn care integration? If

yes, do we need different definitions for distinct stakeholders (policymaker (global/country), donor, provider, mother/family, etc.)

• Integration is a means to an end, not an end in of itself - we are not in pursuit of integration for the sake of integration; rather we want “smart” integration to achieve a specific purpose (better experience of care and outcomes for women and newborns; better value for money, etc.)

• Context matters for smart integration: – Integration must begin by looking at context – Integration strategies must build on and complement established

service delivery platforms and avoid undermining local platforms (e.g. Nigeria ward essential services package)

Recurring Themes….(cont’d) ---------------------------------------------------

• Professional/Institutional interests and power structures must be recognized, understood and co-opted (we must be Judo practitioners...there will be resistance by certain interest groups; e.g. specific provider cadres/professional associations, institutional departments, etc)

• Feasibility of MNH integration approaches varies……by intervention complexity, system readiness, local context, etc.… No simple one-size fits all

• Costs of integrated and non-integrated care for client

and for system? We need more evidence.

Recurring Themes (cont’d) --------------------------------------------------- • Normal and complications care • Integration from woman, family-centered perspective • Integration from system/service delivery perspective • Boundaries of integration? MNH, MNCH, primary care,

primary/specialty coordinated care • We should not chase only “opportunities” in local context but also

be bold about re-designing systems to achieve best outcomes for mothers and newborns

• Institute for Healthcare Improvement (IHI) Triple Aim: Better Value for Cost: – Better care for individuals….experience of care – Improved Population Health – Lower per capita cost of health care

Our Phrases... ---------------------------------------------------

- • Integration vs. “Dis-integration” (J. Lawn) • CFC -content-free contact (R. Atun)

- or do we mean “content-positive contact” (respectful, effective care) versus “content -negative contact” (unsafe, disrespectful care)

• MPU – minimum publishable unit (M. Mitchell) (not conducive to systems approaches/research)

• Cost of Inaction … Cost of Action (India CCT and negative effect on maternal health outcomes – S. Iyengar)

• “One StopShop” • Humanized not commoditized care (rebel table)

Opportunities for smart integration across MNH continuum ANC, Intra-partum, Post-partum

-----------------------------------------------------------------------------------

• Care moment - ANC, intra-partum, post-partum

• Care delivery models

• Care team

• Care settings (household/community and facility)

• Care structure and system: funding, programmatic planning, goals and outcomes

Meeting Objective 3: Develop a list of actions the global maternal and newborn health communities can take to ensure greater programmatic coherence and effectiveness

------------------------------------------------------------------------

Walking the Talk….

Proposed principles of Smart Integration

XXXX (insert principles proposed by Table 5 – unable to capture in time for PPT)

Actions: Point of Service Delivery --------------------------------------------------- • QI approaches and tools to support smart integration and coordination of

care for mothers and newborns, including: – Team-based QI, measurable, feasible common indicators, coordinated training

and support for integrated care – Process mapping across service delivery points – Action plans- goals, team-work

• Establish/improve team-oriented competency-based training and supervision for delivery of integrated and coordinated care for mothers and newborns

• Co-location of maternal and newborn services within a facility (e.g. newborn resuscitation area is not in separate unit from delivery unit)

• Workforce – training, supervision focused on smart integrated care • HMIS – simplified, unified MNH data collection tools (e.g. standardized

record that captures essential maternal and newborn information) • Essential maternal and newborn commodities available and functional at

point of care; joint supply chain management of essential MNH commodities

Actions: National Policy and Programming --------------------------------------------------------------------

• National Policy: Harness and align existing national platforms, policy, guidelines, working groups to support smart integration

• Workforce: review and revise provider and manager competencies to ensure training and supervision that builds capacity of specific cadres and teams of providers to optimally delivery integrated care processes for mothers and newborns

• Communication with decision makers: Develop specific talking points for MOH and decision makers to help them understand importance of smart integration of maternal and newborn care

• Advocacy tools for managers • HMIS – strengthen HMIS to monitor maternal and newborn content/quality and

contact, including smart integration (indicators, data collection tools at facility level and above)

• Merge country TWGs – maternal and newborn TWGs often exist in silos • Use State of the World Midwifery report as a technical resource and advocacy

tool • Develop Centers of excellence to demonstrate and study smart integration of

maternal and newborn services across a range of contexts

Actions: Technical Partners and Donors -----------------------------------------------------

Maintain an MNH integration lens …..

• Global and country-level common messaging

• Unify and coordinate KM platforms across agencies and maternal and newborn communities

• Build the evidence for (and against) including case studies of smart integration for policymakers

• Align MNH global initiatives (ENAP, EPMM, WHO/UNICEF EMEN QI Initiative; WHO Safe Childbirth Checklist program; PMNCH; UN Commission on Neglected Commodities, etc.)

Actions: Technical Partners and Donors (continued)

---------------------------------------------------- Maintain an MNH integration lens ….. • Align investments and technical assistance with national

priorities and strategies ( country-centric approach) • Common Metrics: Support unified measurement

frameworks –contact and coverage and measures of smart integration

• IHI Triple AIM: Make case/build evidence for triple return on investment (experience of care for individual families, population outcomes, and best value for money

• Support /plan joint conferences (e.g. global maternal and newborn conference, country and technical meetings, etc.)

Our Process Going Forward: Next Steps

--------------------------------------------------- • Develop simple MNH integration talking points –

common messaging, case studies, evidence • Create/support unified MNH Knowledge Management

platform(s) • MNH Integration Meeting Advisory group will review

and prioritize meeting recommendations and share action plan

• Get involved with WHO/UNICEF EMEN QI Initiative (standards, facility QI processes, accountability and accreditation) – meeting participants/community of practice can contribute a lot to EMEN QI Initiative and use EMEN as a platform for advocacy and change at all levels

Our Process: Next Steps --------------------------------------------------- • Consider an International Maternal Newborn

global conference with strong emphasis on smart integration themes

• We each and all commit to be champions for smart integration of maternal and newborn care that best serves the needs, values and priorities of women, newborns and their families

• When convening a meeting consider including a focus on both mother and newborn and on themes important for smart MNH integration (e.g. WHO, USAID, Gates supported meetings)

Karim Magana (proverb in Hausa) ---------------------------------------------------

Tsintsiya 'daya ba ta shara 'A single straw doesn't sweep’

We must all together “sweep” the halls of advocacy, politics, research,

policy, systems strengthening, care delivery and respectful discourse with women and families to achieve smart integrated care that meets the needs and priorities of women, newborns and their families